Is this the writing on the wall for First Contact and Advanced Practitioners in the NHS?
MSKMag OutLoudShow Notes
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In May 2026, the British Medical Association, the largest doctors’ union in the UK, published the findings of a survey of over 5,000 doctors on the role of Advanced Practitioners (APs), with 81% saying that the way APs currently work poses a risk to patient safety. This was reflected in a new position statement from the Royal College of Physicians, suggesting that replacing doctors with other roles created ‘a real risk of fragmented care and harm to patient safety’. To understand the degree of antipathy against APs, we must go back to the beginning (This is where, in a film, the swirly spiral denotes we are going back in time (you can hum the atmospheric tune yourselves…)). The Origin Story It’s the millennium, and there is a steady but unmistakable shift from a model of care that was in place from the inception of the NHS in the 1940s to when I qualified in the early 2000s. The 1-in-2 on-call rotas are rapidly becoming a thing of the past as Modernising Medical Careers and the European Working Time Directive from 2004 onwards reduced the average number of hours worked by doctors and the old ‘firm’ structures (Consultant, Registrar, SHO, HO etc) made way for newer ways of working. Whilst the number of hours doctors worked decreased, the population continued to age and grow, creating a tidal wave of increasing complexity and acuity, placing services under unprecedented demand. The number of patients registered with NHS GPs in England grew significantly, from roughly 50 million in 2020 to just under 64 million by 2025. To meet this growing demand, the Health Foundation suggests that a further 3,500 GPs will be needed by 2031. But it takes a long time to train a doctor; 10+ years as a minimum for GPs, and the number of full-time equivalent GPs has dropped by 458 since 2015. Step into the breach: non-doctor roles. By the time of the NHS long-term plan in 2019, early pilots of first-contact physiotherapists had shown they could be useful members of the primary care team. In 2020, the National Evaluation of the First Contact Practitioner (FCP) model of primary care evaluated 240 FCPs from 40 services in England and found that FCPs were acceptable to patients, produced positive outcomes, and reduced GP workload [1].
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It always struck me as bizarre that sports medicine and musculoskeletal specialties deal with pain and dysfunction from head to toe in the human body, yet offer little health literacy or inclusion of the pelvic floor. Traditionally considered taboo and someone else’s remit, men and women with issues affecting the pelvic floor have largely suffered in silence. Thankfully, change is afoot, and healthcare is finally evolving. There is much more awareness, inclusion, and understanding of this unique body area and the role that it plays. For anyone playing catch up, the pelvic floor is a group of muscles spanning the base of the pelvic outlet in layers. While both men and women have a pelvic floor, the pelvic outlet is wider in females than in males and it also contains an extra orifice – the vagina [1]. That’s right, we went there. We said the ‘V’ word. Because just like vulva, or vestibule, the vagina is simply an anatomical term. It needn’t be embarrassing or taboo. Some of you will be long enough in the tooth to remember when the word ‘breast’ was taboo. However, with healthcare campaigns for breast cancer and breastfeeding, this term became an anatomical norm. We need to do the same for the pelvic floor and its related anatomy and physiology. What does the pelvic floor do? In both men and women, the pelvic floor serves to control the bladder and bowel (maintain continence), empty the bladder and bowel (voiding and defecation) and support sexual function (arousal and climax). In women, the pelvic floor also plays an important role in pelvic organ support. Remember that extra orifice I mentioned earlier…well this area is high risk for connective tissue laxity and defects meaning that the pelvic organs (bladder, uterus, rectum) can descend into the vaginal cavity causing symptoms of heaviness, pressure and a sensation of ‘something in the vagina’. What are the signs and symptoms of pelvic floor dysfunction? If the pelvic floor is not doing its job, any of its roles can become compromised. This may manifest in leaking from the bladder or bowel, inability to fully empty the bladder or bowel, pain ‘down there’, sexual dysfunction (compromised erection, dyspareunia, pain with climax) or heaviness and pressure in the vaginal region (for women) [2]. A full list of sex-specific signs and symptoms of pelvic floor dysfunction can be seen in Table 1. Table 1 - signs and symptoms of pelvic floor dysfunction in men and women Who gets pelvic floor dysfunction? Pelvic floor dysfunction can affect any man, woman or child, however it is particularly problematic for women, especially during transitional life events, such as pregnancy/childbirth and the menopause [1]. One in three women will experience pelvic floor dysfunction [3] and for those that engage in sport, the prevalence of symptoms varies according to the load demands of the activity. For example 61% of netballers leak urine [4], up to 43% of female rugby players leak [5], and 32% of gymnasts experience incontinence [6]. Structural changes associated with vaginal childbirth and aging, as well as lower levels of oestrogen to lubricate and bulk out the tissues can increase the odds of experiencing pelvic floor dysfunction. However, even young adolescent females can leak urine due to the load demands of their sport. For example, in athletics and gymnastics, stress urinary incontinence (the involuntary leakage of urine during activities involving high levels of intra-abdominal pressure) is commonly experienced. Yet no-one is doing anything about it. No one is screening. No one is signposting. No one is educating these younger athletes that pelvic floor symptoms are not to be expected and normalised. Or that they simply indicate that the sporting demands exceed the load capacity at the pelvic floor. If this was any other area of sports or MSK practice, would we settle for a load capacity that does not meet the demands of the sport?! Why is this relevant to every therapist, no matter their di
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com
This is a free preview of a paid episode. To hear more, visit mskmag.substack.com